Form 1041-A U.S. Information Return
(Rev. December 1993) Trust Accumulation of Charitable Amounts OMB No. 1545-0094
Expires 11-30-96
Department of the Treasury
Internal Revenue Service For calendar year 19
Name of trust Employer identification number
Name of trustee
Number, street, and room or suite no. (or P.O. box)
City, state, and ZIP code
Part I Income and Deductions (See the instructions for Form 1041 or Form 5227.) If total income is $25,000 or
less, skip lines 1–8.
1 Interest income 1
2 Dividends 2
3 Business income or (loss) (attach Schedule C or C-EZ (Form 1040)) 3
4
Income
4 Capital gain or (loss) (attach Schedule D (Form 1041))
5 Rents, royalties, partnerships, other estates and trusts, etc. (attach Schedule E (Form 1040)) 5
6 Farm income or (loss) (attach Schedule F (Form 1040)) 6
7 Ordinary gain or (loss) (attach Form 4797) 7
8 Other income (state nature of income) 8
9 Total income (combine lines 1 through 8) 9
10 Interest 10
Deductions
11 Taxes 11
12 Charitable deduction (itemize by charitable purpose; include payee’s name and address) 12
13 Trustee fees 13
14 Attorney, accountant, and return preparer fees 14
15 Other deductions (attach schedule) 15
Part II Distributions of Income Set Aside for Charitable Purposes (see instructions)
16 Accumulated income set aside in prior tax years for which a deduction was claimed under section
642(c) 16
17 Income set aside in prior tax years for which a deduction was claimed under section 642(c)
and which was distributed during the current tax year (itemize by charitable purpose; include
payee’s name and address)
a 17a
b 17b
c 17c
d 17d
e 17e
18 Total (add lines 17a through 17e) 18
19 Balance (subtract line 18 from line 16) 19
20 Income set aside during the current tax year for which a deduction was claimed under section
642(c) (included in Part I, line 12) 20
21 Carryover (add lines 19 and 20) 21
Part III Distributions of Principal for Charitable Purposes (see instructions)
22 Principal distributed in prior tax years for charitable purposes 22
23 Principal distributed during the current tax year for charitable purposes (itemize by charitable
purpose; include payee’s name and address)
a 23a
b 23b
c 23c
d 23d
e 23e
24 Total (add lines 23a through 23e) 24
For Paperwork Reduction Act Notice, see instructions. Cat. No. 10615B Form 1041-A (Rev. 12-93)
Form 1041-A (Rev. 12-93) Page 2
Balance Sheets (see instructions). If line 9, page 1, is $25,000 or less, complete only lines 38, 42,
Part IV and 45 (see instructions).
(a) Beginning-of- (b) End-of-Year
Assets Year Book Value Book Value
25 Cash—non-interest bearing 25
26 Savings and temporary cash investments 26
27a Accounts receivable 27a
b Less: allowance for doubtful accounts 27b
28a Notes and loans receivable 28a
b Less: allowance for doubtful accounts 28b
29 Inventories for sale or use 29
30 Prepaid expenses and deferred charges 30
31 Investments—U.S. and state government obligations (attach schedule) 31
32 Investments—corporate stock (attach schedule) 32
33 Investments—corporate bonds (attach schedule) 33
34a Investments—land, buildings, and equipment: basis 34a
b Less: accumulated depreciation 34b
35 Investments—other (attach schedule) 35
36a Land, buildings, and equipment: basis 36a
b Less: accumulated depreciation 36b
37 Other assets (describe ) 37
38 Total assets (add lines 25 through 37) 38
Liabilities
39 Accounts payable and accrued expenses 39
40 Mortgages and other notes payable (attach schedule) 40
41 Other liabilities (describe ) 41
42 Total liabilities (add lines 39 through 41) 42
Net Assets
43 Trust principal or corpus 43
44 Undistributed income and profits 44
45 Total net assets (add lines 43 and 44) 45
46 Total liabilities and net assets (add lines 42 and 45) 46
Under penalties of perjury, I declare that I have examined this return, including accompanying schedules and statements, and to the best of my knowledge
Please and belief, it is true, correct, and complete. Declaration of preparer (other than trustee) is based on all information of which preparer has any knowledge.
Sign
Here Signature of trustee or officer representing trustee Date
Preparer’s Date
Paid Check if self-
signature employed
Preparer’s Firm’s name (or yours,
Use Only if self-employed)
and address ZIP code
Form 1041-A (Rev. 12-93) Page 3
Paperwork Reduction ● A split-interest trust described in Public Inspection
section 4947(a)(2) if all transfers of See Regulations section 301.6104(b)–
Act Notice corpus to the trust occurred before May 1(d) for the procedures to request public
We ask for the information on this form 27, 1969, and no section 642(c) inspection of this form.
to carry out the Internal Revenue laws of deduction is claimed.
the United States. You are required to When To File
give us the information. We need it to Specific Instructions
File Form 1041-A on or before April 15
ensure that you are complying with
following the close of the calendar year.
Part II—Distributions of
these laws and to allow us to figure and Income Set Aside For
collect the right amount of tax. Where To File Charitable Purposes
The time needed to complete and file Please mail Form 1041-A to the Internal
this form will vary depending on Revenue Service Center listed below for Lines 17a–17e.—Provide a listing in
individual circumstances. The estimated the state where the trustee lives or has a sufficient detail for each class of activity
average time is: principal place of business. for which a disbursement was made,
and a charitable deduction under section
Recordkeeping 24 hr., 9 min. Please mail to
the following 642(c) was taken.
Learning about the If you are Internal Revenue Such amounts permanently set aside
law or the form 3 hr., 20 min. located in Service Center
must be earned from amounts
Preparing the form 8 hr., 32 min. transferred to the trust before October 9,
Alabama, Arkansas, Florida,
Copying, assembling, Georgia, Louisiana, Mississippi, 1969.
Atlanta, GA 39901
North Carolina, South Carolina, Do not merely enter the category (i.e.,
and sending the Tennessee
form to the IRS 1 hr., 20 min. religious, charitable, scientific, literary, or
Arizona, Colorado,
Kansas, New Mexico, educational), but also enter the purpose
If you have comments concerning the Oklahoma, Texas, Austin, TX 73301 of the deduction. For example,
accuracy of these time estimates or Utah, Wyoming “payments of $4,000 to indigent persons
suggestions for making this form more Indiana, Kentucky, for medical purposes,” or a “grant of
simple, we would be happy to hear from Michigan, Ohio, Cincinnati, OH 45999
West Virginia $25,000 to equip the chemistry lab at a
you. You can write to both the Internal university.”
Revenue Service, Attention: Reports Alaska, California, Hawaii,
Idaho, Nevada, Oregon, Fresno, CA 93888
Clearance Officer, PC:FP, Washington, Washington Part III—Distributions of
DC 20224; and the Office of Connecticut, Maine, Principal for Charitable
Management and Budget, Paperwork Massachusetts, New
Reduction Project (1545-0094), Hampshire, New York,
Holtsville, NY 00501 Purposes
Rhode Island, Vermont
Washington, DC 20503. DO NOT send Lines 23a–23e.—Provide a listing in
Illinois, Iowa, Minnesota, sufficient detail, similar to the examples
the tax form to either of these offices. Missouri, Montana,
Instead, see Where To File on this page. Nebraska, North Dakota, Kansas City, MO 64999 provided above, for each class of
South Dakota, Wisconsin activity for amounts paid out of principal
General Instructions Delaware, District of for charitable purposes.
Columbia, Maryland,
New Jersey, See the instructions for Form 1041,
Section references are to the Internal Pennsylvania, Virginia, any Philadelphia, PA 19255 U.S. Fiduciary Income Tax Return, for
Revenue Code unless otherwise noted. U.S. possession, or more information regarding the
foreign country
A Change To Note allowance of deductions for amounts
permanently set aside for a charitable
The Balance Sheet in Part IV has been Penalties purpose.
substantially revised to conform with the Section 6652(c)(2) provides for separate
one used in Form 5227, Split-Interest penalties of $10 a day, up to a maximum Part IV—Balance Sheets
Trust Information Return. of $5,000, against both the trust and the Complete the balance sheets using the
trustee for not filing Form 1041-A on accounting method the trust uses in
Purpose of Form time, unless there is reasonable cause. keeping its books and records. All filers
Use Form 1041-A to report the The law also provides penalties for filing must complete columns (a) and (b).
charitable information required by a false or fraudulent return.
section 6034 and the related regulations. Assets
Rounding Off to Whole When space is provided to the left of
Who Must File Dollars column (a) for reporting receivables and
The trustee must file Form 1041-A for: You may show the money items on the the related allowance for doubtful
● A trust that claims a charitable or return and accompanying schedules as accounts or depreciable assets and
other deduction under section 642(c), or whole-dollar amounts. To do so, drop accumulated depreciation, enter the
● A split-interest trust described in amounts less than 50 cents and end-of-year figures.
section 4947(a)(2), including charitable increase any amounts from 50 to 99 Line 25—Cash-non-interest bearing.—
remainder trusts (section 664) and cents to the next dollar. Enter the amount of cash on deposit in
pooled income funds (section 642(c)(5)). checking accounts, deposits in transit,
Attachments change funds, petty cash funds, or any
The trustee does not have to file Form If you need more space, attach separate
1041-A for: other non-interest bearing accounts. Do
sheets showing the same information in not include advances to employees or
● A trust that is required to distribute the same order as on the printed forms. officers or refundable deposits paid to
currently to the beneficiaries all the Show the totals on the printed forms. suppliers or others.
income for the tax year determined Enter the trust’s employer
under section 643(b) and related Line 26—Savings and temporary cash
identification number (EIN) on each investments.—Enter the total of cash in
regulations, sheet. Also, use sheets that are the savings or other interest-bearing
● A charitable trust described in section same size as the forms and indicate accounts and temporary cash
4947(a)(1), or clearly the line of the printed form to investments, such as money market
which the information relates.
Form 1041-A (Rev. 12-93) Page 4
funds, commercial paper, certificates of Lines 31, 32, and 33—Investments— Liabilities
deposit, and U.S. Treasury bills or other government obligations, corporate Line 39—Accounts payable and
governmental obligations that mature in stocks, and corporate bonds.—Enter accrued expenses.—Enter the total
less than 1 year. the book value (which may be market accounts payable to suppliers and
Line 27—Accounts receivable.—Enter value) of these investments. Attach a others, and accrued expenses such as
the total accounts receivable (reduced schedule that lists each security held at salaries payable, accrued payroll taxes,
by the corresponding allowance for the end of the year and shows whether and interest payable.
doubtful accounts) that arose from the the security is listed at cost (including
the value recorded at the time of receipt Line 40—Mortages and other notes
sale of goods and/or the performance of payable.—Attach a schedule showing,
services. Claims against vendors or in the case of donated securities) or
end-of-year market value. Do not include as of the end of the year, the total
refundable deposits with suppliers or amount of all mortgages payable, and
others may be reported here if not amounts on line 26. Government
obligations reported on line 31 are those for each nonmortgage note payable, the
significant in amount. If significant in lender’s name and the other information
amount, report them (with any advances that mature in 1 year or more. Debt
securities of the U.S. government may specified in the line 28 instructions.
to employees or officers) on line 37,
Other assets. be reported as a single total rather than Line 41—Other liabilities.—Enter the
itemized. Obligations of state and book value of any trust liabilities that
Line 28—Notes and loans have not been reported on lines 39 or
municipal governments may also be
receivable.—Enter the combined total of 40. If more space is needed, attach a
reported as a lump-sum total. Do not
notes receivable and net loans separate schedule with a description of
combine U.S. government obligations
receivable (including receivables due the liability and amount.
with state and municipal obligations on
from officers, directors, trustees, and
the attached schedule.
other disqualified persons). In an Signature
attached schedule, show the following Line 34—Investments—land, buildings,
information (preferably in columnar and equipment.—Attach a schedule of Form 1041-A must be signed by the
format): all land, buildings, and equipment that trustee or by an authorized
are held for investment purposes, such representative.
● Borrower’s name and title.
as rental properties. List the cost or If you, as trustee (or an employee or
● Original amount. other basis of these assets, officer of the trust), fill in Form 1041-A,
● Balance due. accumulated depreciation, and the Paid Preparer’s space should be left
● Date of note. end-of-year book value. blank. If someone prepares this return
● Maturity date. Line 35—Investments—other.—Enter without charge, that person should not
● Repayment terms. the amount of all other investment sign the return.
holdings not reported on lines 31 Generally, anyone who is paid to
● Interest rate. through 34. Attach a schedule prepare a tax return must sign the return
● Security provided by the borrower. describing each of these investments and fill in the other blanks in the Paid
● Purpose of the loan. held at the end of the year. List the cost, Preparer’s Use Only area of the return.
● Description and fair market value of or other basis, and the end-of-year book
If you have questions about whether a
the consideration furnished by the value.
preparer is required to sign the return,
lender. Line 36—Land, buildings, and please contact an IRS office.
Line 29—Inventories for sale or use.— equipment.—Attach a schedule of all
The person required to sign the return
Enter the amount of materials, goods, land, buildings, and equipment that are
as the preparer must complete the
and supplies purchased or manufactured NOT held for investment purposes, such
required preparer information and:
by the trust and held for sale or use in as the trust’s offices. List the cost or
other basis of these assets, ● Sign it, by hand, in the space provided
some future period. for the preparer’s signature. (Signature
accumulated depreciation, and
Line 30—Prepaid expenses and end-of-year book value. stamps and labels are not acceptable.)
deferred charges.—Enter the amount of ● Give the trustee a copy of the return
short-term and long-term prepayments Line 37—Other assets.—Enter the book
value of any trust assets that have not in addition to the copy to be filed with
of future expenses attributable to one or the IRS.
more future accounting periods. been reported on lines 25 through 36. If
Examples include prepayments of rent, more space is needed, attach a separate
insurance, and pension costs. schedule with a description of the asset,
date acquired, and end-of-year book
value.
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